Fetal Decompensation Research Articles

Updated NICE Cardiotocograph (CTG) Guideline: Is it Suspicious or Pathological?

Cardiotocograph (CTG) trace was introduced into clinical practice in 1960s as a tool to record the changes in the fetal heart rate (cardio) in response to ongoing uterine contractions (toco). The intention was to timely recognise the features of fetal decompensation so that immediate action could be taken to avoid hypoxic ischaemic encephalopathy (HIE) and/ or intrapartum hypoxia-related perinatal deaths, without increasing unnecessary operative interventions to the mother. However, very unfortunately, unlike other tools in clinical medicine, CTG was introduced into clinical practice without any randomised controlled trials or robust scientific studies not only to confirm its effectiveness, but to determine the CTG features which actually reflected fetal central organ oxygenation. This chasm of deficiency of knowledge of fetal physiology created a vacuum of understanding regarding what features were reflecting fetal compromise. Regrettably, this vacuum was soon filled by prominent obstetricians from national societies who were presumed to have the knowledge, but they began the arduous journey of classifying decelerations which are normal fetal cardioprotective reflexes, and they misclassified them as signs of “fetal distress”. Classification of these decelerations based on the observed morphology into “reassuring” and “nonreasoning” categories has resulted in disastrous consequences for women and babies. In the UK, since the publication of the first CTG guideline in 2001, due to continuing lack of knowledge and confusion, these guidelines were repetitively revised in 2007, 2014, 2017 and 2022. Despite the international consensus guidelines of physiological interpretation of CTG produced by 44 CTG experts from 14 countries which recommended classification of CTG traces based on the type of fetal hypoxia and fetal response to stress, the latest revised guideline produced by the National Institute of Health and Care Excellence (NICE), had continued the illogical approach of grouping arbitrary features into different categories and then randomly combining them to classify the CTG traces into “Normal, Suspicious and Pathological”. Therefore, all practising clinicians who are focussed on protecting their patients from harm have a responsibility to ask the question whether the revised NICE CTG Guideline itself is suspicious or pathological from a patient safety perspective.

Treatment of Arrhythmias During Pregnancy.

Cardiac disease is the most common cause of maternal mortality in developed nations. Cardiac arrhythmias are frequent among patients with structural heart disease and may require immediate treatment to prevent hemodynamic instability leading to acute maternal and fetal decompensation. Antiarrhythmic therapy during pregnancy should follow the same principles recommended for nonpregnant individuals. Although multidisciplinary management is recommended, obstetricians, and maternal-fetal medicine specialists may sometimes need to emergently recognize and treat rhythm anomalies before support services become available.

Prediction of Neonatal Acidosis Based on the Type of Fetal Hypoxia Observed on the Cardiotocograph (CTG)

Cardiotocograph (CTG) was introduced into clinical practice to promptly recognize the features of intrapartum fetal hypoxic stress, so that timely action could be taken to avoid hypoxic-ischaemic encephalopathy (HIE) and perinatal deaths. However, the current systematic evidence suggests that the introduction of CTG into clinical practice over 50 years has not resulted in improvement in the rates of cerebral palsy or perinatal deaths. This is because most fetuses are able to withstand intrapartum hypoxic stresses without sustaining damage, and if the features of fetal compensatory responses are erroneously considered as “pathological”, “Abnormal” or “Category III” CTG tracing, it would lead to an exponential increase in unnecessary operative interventions without any improvement in perinatal outcomes. Neonatal acidosis at birth, determined by the estimation of pH in the umbilical artery has been considered as a surrogate marker of poor perinatal outcome. This is because significant intrapartum fetal hypoxic stress which leads to fetal decompensation, would lead to the onset of anaerobic metabolism and production of lactic acid in fetal tissues and organs. Entry of lactic acid into the fetal systemic circulation may cause damage to fetal central organs resulting in organ damage and death, and this lactate may lower the pH in the umbilical artery. Understanding the different types of fetal hypoxia on the CTG trace may help practicing clinicians to predict the rate of fall in fetal pH, and therefore, predict the umbilical cord pH at birth. It is important to appreciate that non-hypoxic pathways of fetal compromise such as chorioamnionitis may not be associated with low umbilical arterial pH at birth. Fetal pathophysiological approach to CTG interpretation based on deeper understanding of types of intrapartum hypoxia and features of non-hypoxic pathways of injury may help avoid the onset of neonatal metabolic acidosis and improve perinatal outcomes.

Induction of labor in late FGR.

Late-onset FGR is a peculiar condition characterized by the inability for the fetus to reach its growth potential diagnosed from 32 weeks of gestation. Placental insufficiency is among the leading causes of late FGR and is commonly due to a primary maternal cardiovascular non-adaptation potentially leading to fetal decompensation during labor especially once exposed to uterine hyperstimulation. Abnormalities that usually characterize late FGR include reduced fetal growth, decreased Amniotic Fluid Index, and loss of fetal heart rate variability at CTG. Fetal hemodynamics study by Doppler ultrasound significantly improved management of pregnancies affected by fetal growth restriction. A major issue when dealing with pregnancies complicated by late FGR is how to induce these women. Induction of labor (IOL) can be essentially accomplished by pharmacological and non-pharmacological agents. Recent studies suggested that the pregnancies complicated by late FGR should undergo a tailored approach for IOL in view of the higher risk of fetal decompensation following uterine hyperstimulation. The present review aims to provide an up to date on the different types of IOL which can guide clinical management.

Role of doppler in the middle cerebral artery in prediction of fetal distress during labor in uncomplicated pregnancies at 40 weeks and beyond

The aim of this study was to reveal correlation between Doppler in the fetal middle cerebral artery and fetal decompensation during labor in uncomplicated pregnancies at 40 weeks and beyond. We by means of ultrasound Doppler examined 260 women at 40 to 42 weeks of uncomplicated pregnancy 48 hours before delivery, with fetal condition assessed subsequently during labor and immediately after delivery. We found out that in the group of women with caesarean section caused by fetal distress during labor, pulsatility indices in the middle cerebral artery evaluated just before labor were significantly lower than in the group of women whose fetus had better condition during labor. The same trend was observed when comparing Doppler velocimetry using the fetal cerebroplacental ratio. Moreover, we identified that in the group of women with newborns having Apgar 7 and less, middle cerebral artery measured less than 48 hours before delivery were lower than in the group of women having babies in better conditions. Furthermore, as result of this study, the trigger threshold for PI was found to be 0.835, below which fetuses have adverse perinatal outcome during labor. Thus, it was shown that Doppler in the fetal middle cerebral artery in uncomplicated pregnancies at 40 weeks and beyond could predict fetal distress and avoid hypoxic brain damage to the fetus during labor.

Recognition of chronic hypoxia and pre-existing foetal injury on the cardiotocograph (CTG): Urgent need to think beyond the guidelines

Chronic utero-placental insufficiency may result in progressive hypoxia culminating in fetal decompensation and acidosis and this is termed ‘chronic’ or ‘long-standing’ hypoxia. It is essential to recognise the features of chronic hypoxia on the CTG trace so as to institute timely and appropriate action. The current guidelines may not capture a fetus who starts labour already compromised or limited in its ability to compensate for hypoxic or mechanical stresses during labour. The aim of this short review is to explore the CTG features that allow the clinician to recognise a fetus who may present with an antenatal insult such as chronic hypoxia, anaemia, infection, fetal arrhythmias and preexisting non-hypoxic brain injury.

Fetal Intrauterine Transfusion

ABSTRACT Fetal anemia is a recognizable and treatable condition. It requires identification of the etiology to plan a comprehensive treatment strategy. Fetal blood transfusions help tide over crisis and avert fetal cardiovascular decompensation or deterioration due to the anemia. Based on the cause and the fetal condition, the timing and requirement for transfusion are determined. At present, noninvasive monitoring with fetal middle cerebral arterial Doppler peak systolic velocity is the standard for monitoring and diagnosis of fetal anemia. How to cite this article Indersen A. Fetal Intrauterine Transfusion. World J Anemia 2017;1(1):27-29.

The natural history of an umbilical cord hemangioma

Umbilical cord hemangiomas are rare, and the natural history is poorly understood. We present a case where the clinical course was complicated by distal umbilical cord edema, episodes of proximal obstruction of umbilical artery blood flow, transient fetal pleural and pericardial effusions, and position-dependent abnormal fetal heart rate monitoring with periods of sustained fetal tachycardia. Delivery was performed for fetal growth restriction with abnormal fetal surveillance. This case highlights possible mechanisms for fetal decompensation as well as the importance of a multifaceted approach to the management of an umbilical cord mass using multiple tools for fetal assessment. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:455-458, 2016.

Induction of Labor for Term Small-for-Gestational-Age Fetuses

Induction of labor (IOL) when the fetus appears small for gestational age (SGA) toward term may improve perinatal outcomes and prevent fetal death. If these fetuses are small as a variant of the normal spectrum, early induction may not improve outcomes and may cause obstetric complications. This study was undertaken to determine the impact of early IOL on neonatal outcomes and rates of maternal obstetric interventions in SGA term infants. The cohort included all term singleton deliveries and their neonatal outcomes occurring in 2004 to 2008. Maternal and neonatal outcomes of term (37–42 weeks) growth-restricted singleton deliveries were analyzed. Small for gestational age was defined as birth weight lower than the 10th percentile adjusted for gestational age and sex. The exposed group, termed early-induction SGA group, included women giving birth after IOL for suspected intrauterine growth restriction (IUGR) of a singleton SGA neonate at 37 to 39 weeks. The unexposed group, or no-early-induction SGA group, included women giving birth at 40 weeks of gestation or later and those who gave birth spontaneously to term SGA neonates at 37 to 39 weeks. Maternal characteristics, pregnancy and neonatal complications, and obstetric interventions were compared to evaluate benefits/drawbacks of early term IOL for IUGR. Of 37,342 women who had a singleton neonate at 37 weeks of gestation or later, 2378 (6.36%) neonates were born SGA. The early-induction and no-early-induction SGA groups included 445 and 1933 neonates, respectively. Most obstetric complications were similar in the 2 groups. Women in the early-induction group had significantly more hypertensive complications and a higher rate of cesarean deliveries compared with the unexposed group, and only 65.5% reached noninstrumental vaginal delivery (P < 0.0001). Neonatal Apgar scores at 1 and 5 minutes and sex were similar between the 2 groups. Compared with the unexposed group, the early-induction group had higher rates of hyperbilirubinemia necessitating phototherapy (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.21–2.53) and hypoglycemia (OR, 2.38; 95% CI, 1.56–3.62). Two neonates in the early-induction group had respiratory complications. Necrotizing enterocolitis, sepsis, adverse neurologic outcomes, and need for resuscitation were rare and similar in both groups. No neonates died. The risk for any adverse neonatal outcome was ~2 times higher for the early-induction compared with the unexposed group (OR, 1.95; 95% CI, 1.46–2.61; P < 0.0001). The most significant danger in abstaining from IOL for IUGR at term is intrauterine fetal death. Of 37,342 singleton deliveries, 33 fetal deaths occurred at 37 to 42 weeks, 0.88 cases per 1000 live births at term; only 1 was an SGA fetus at 37 weeks. The risk for intrauterine fetal demise at term for non–early-induction SGA was 0.52 cases per 1000 live births, similar to that of the general term population (OR, 0.57; 95% CI, 0.08–3.85; P = 0.99). For suspected IUGR at term, awaiting spontaneous labor risks fetal decompensation, yet active IOL might increase rates of obstetric interventions and neonatal complications of early term delivery. This study found no apparent neonatal benefit for early term IOL for SGA neonates.

Acute and chronic fetal anemia as a result of fetomaternal hemorrhage.

Introduction. Fetomaternal hemorrhage represents a transfer of fetal blood to the maternal circulation. Although many etiologies have been described, most causes of fetomaternal hemorrhage remain unidentified. The differentiation between acute and chronic fetomaternal hemorrhage may be accomplished antenatally and may influence perinatal management. Case. A 36-year-old gravida 6 para 3 presented at 37 and 5/7 completed gestational weeks with ultrasound findings suggestive of chronic fetal anemia such as right ventricular enlargement, diminished cerebral vascular resistance, and elevated middle cerebral artery end-diastolic velocity. On the other hand, signs of acute fetal decompensation such as deterioration of the fetal heart tracing, diminished biophysical score, decreased cord pH, and increased cord base deficit were noted. Following delivery, the neonate's initial hemoglobin was 4.0 g/dL and the maternal KB ratio was 0.015 indicative of a significant fetomaternal hemorrhage. Discussion. One should consider FMH as part of the differential diagnosis for fetal or immediate neonatal anemia. We describe a unique case of FMH that demonstrated both acute and chronic clinical features. It is our hope that this case will assist practitioners in differentiating acute FMH that may require emergent delivery from chronic FMH which may be able to be expectantly managed.

Intervillous circulation in intra-uterine growth restriction. Correlation to fetal well being

Magnetic resonance imaging requested for a potentially serious indication, provided a unique opportunity to explore the intervillous circulation of placentas from pregnancies complicated by Intra Uterine Growth Restriction (IUGR) and to compare them to normal cases. This allowed an innovative characterization of in vivo utero-placental blood flow, correlating a compromised intervillous circulation in IUGR to the deterioration of fetal condition. MR imaging was requested to rule out suspected posterior placental adhesive disorders in 26 patients. Twelve patients had fetuses appropriate for gestational age, while in 14 patients fetuses were affected by severe IUGR. Multiphasic dynamic contrast-enhanced sagittal sequences were acquired and a quantitative analysis of signal intensity and enhancement kinetics was performed for both the entire placenta and for selected regions. Images disclosed a homogeneous perfusion overall the placenta in normal cases, while IUGR placentas displayed a slow intervillous blood flow, along with many patchy unperfused areas. Intermittent stops worsen the perfusion dynamics of the intervillous mostly in IUGR cases with an elevated ductus venosus pulsatility index. In conclusion, we proved that in IUGR placenta maternal placental blood flow is extremely compromised and that superimposed dynamic phenomena concur to worsen the intervillous circulation leading to an end-stage fetal decompensation.

Prenatal diagnosis of thrombosis of the dural sinuses: report of six cases, review of the literature and suggested management

To describe and assess the sonographic findings, evolution and clinical implications of thrombosis of the fetal dural sinuses. We compiled a multicenter report of the outcomes of five cases with a prenatal diagnosis of thrombosis of the dural sinuses, and one case in which thrombosis of the dural sinus was diagnosed at necroscopy after termination of pregnancy. Prognostic factors are discussed, and suggestions made for prenatal and postnatal management. The mean (range) gestational age at diagnosis of thrombosis of the dural sinuses in the five cases in which it was made prenatally was 25.2 (22-31) weeks. In these five cases, diagnosis was made by sonography and confirmed by magnetic resonance imaging (MRI), which showed a blood clot in the region of the torcular herophili. Three of the six cases delivered vaginally with favorable sonographic findings, and normal clinical neurological development. Two pregnancies were terminated at the request of the parents. In one of these cases the prognosis was poor, with signs of fetal decompensation or cardiac failure; the pregnancy was terminated and necropsy revealed thrombosis of the occipital dural sinuses associated with a hemangioma. One infant, in whom the thrombosis developed in conjunction with a dural sinus malformation, died at 4 months of age. Thrombosis of the cerebral venous circulation can occur antenatally and is detectable by fetal real-time and color Doppler ultrasound examination. A review of the literature supports targeted evaluation of the fetus by serial ultrasound imaging and MRI to help guide the diagnosis, and to improve the counseling and management of such cases. Partial or total regression, isolated abnormality, absence of fetal decompensation or signs of cardiac failure and favorable clinical evolution are suggestive of favorable prognosis. In such cases, non-interventional neonatal management is recommended.

A case of left isomerism with early fetal decompensation

A case of left isomerism with early fetal decompensation

OC111: Cardiocirculatory changes in IUGR fetuses: longitudinal quantitative Doppler analysis

Longitudinal measurements of quantitative flow (QF) could clarify compensatory mechanisms to fetal hypoxia, and suggest predictive factors of fetal decompensation and adverse outcome. Our aims were to analyse in IUGR fetuses longitudinal changes of QF in umbilical vein (UV), ductus venosus (DV) and left cardiac output (LCO) and to identify which cardiovascular pattern is more frequently associated with adverse outcome. In 33 IUGR fetuses, two consecutive examinations were retrospectively considered: the last scan (LAST) within 3 days before delivery and the previous exam (FIRST) within 8 days before LAST. Doppler QF was measured at three different sites: intra-amniotic UV, DV and ascending aorta, according to a standardized methodology. QF changes were compared between alive babies and perinatal deaths. A subset of viable fetuses delivered between 28 to 32 weeks was separately considered. QF changes suggestive of fetal decompensation (UV flow reduction, DV dilatation, DV flow increase, LCO reduction) were considered as a variation > 10% from FIRST and LAST examination. Timing of delivery was independently decided by the clinical staff. The gestational age at delivery was 29 ± 3.5 weeks (mean ± SD); the weight at delivery was 880 ± 450 g (mean ± SD). In IUGR fetuses a progressive reduction in UV flow, associated with decreased LCO, in presence of a dilated DV with unexpected reduced ductal flow, could more likely predict fetal decompensation and perinatal death. Presence of reverse shunt from umbilical sinus (US) to DV indicated liver flow deprivation and neonatal methabolic damages.

OC112: Integrated fetal testing most accurately predicts perinatal outcome in intrauterine growth restriction (IUGR)

Objective: Longitudinal measurements of quantitative flow (QF) could clarify compensatory mechanisms to fetal hypoxia, and suggest predictive factors of fetal decompensation and adverse outcome. Our aims were to analyse in IUGR fetuses longitudinal changes of QF in umbilical vein (UV), ductus venosus (DV) and left cardiac output (LCO) and to identify which cardiovascular pattern is more frequently associated with adverse outcome. Methods: In 33 IUGR fetuses, two consecutive examinations were retrospectively considered: the last scan (LAST) within 3 days before delivery and the previous exam (FIRST) within 8 days before LAST. Doppler QF was measured at three different sites: intraamniotic UV, DV and ascending aorta, according to a standardized methodology. QF changes were compared between alive babies and perinatal deaths. A subset of viable fetuses delivered between 28 to 32 weeks was separately considered. QF changes suggestive of fetal decompensation (UV flow reduction, DV dilatation, DV flow increase, LCO reduction) were considered as a variation >10% from FIRST and LAST examination. Timing of delivery was independently decided by the clinical staff. Results: The gestational age at delivery was 29 ± 3.5 weeks (mean ± SD); the weight at delivery was 880 ± 450 g (mean ± SD).

OC113: Abnormal ductus venosus Doppler independently predicts poor perinatal outcome in fetuses delivered for severe early placental insufficiency: a multicenter cohort study

Objective: Longitudinal measurements of quantitative flow (QF) could clarify compensatory mechanisms to fetal hypoxia, and suggest predictive factors of fetal decompensation and adverse outcome. Our aims were to analyse in IUGR fetuses longitudinal changes of QF in umbilical vein (UV), ductus venosus (DV) and left cardiac output (LCO) and to identify which cardiovascular pattern is more frequently associated with adverse outcome. Methods: In 33 IUGR fetuses, two consecutive examinations were retrospectively considered: the last scan (LAST) within 3 days before delivery and the previous exam (FIRST) within 8 days before LAST. Doppler QF was measured at three different sites: intraamniotic UV, DV and ascending aorta, according to a standardized methodology. QF changes were compared between alive babies and perinatal deaths. A subset of viable fetuses delivered between 28 to 32 weeks was separately considered. QF changes suggestive of fetal decompensation (UV flow reduction, DV dilatation, DV flow increase, LCO reduction) were considered as a variation >10% from FIRST and LAST examination. Timing of delivery was independently decided by the clinical staff. Results: The gestational age at delivery was 29 ± 3.5 weeks (mean ± SD); the weight at delivery was 880 ± 450 g (mean ± SD).

Spontaneous hypoxia in multiple pregnancies is associated with early fetal decompensation and enhanced T-wave elevation during brief repeated cord occlusion in near-term fetal sheep

The purpose of this study was to examine the hypothesis that fetuses from multiple pregnancies who exhibited spontaneous, stable hypoxia would show more rapid development of metabolic acidosis and hypotension during short repeated episodes of umbilical cord occlusion than normoxic singleton or twin fetuses and, if this proved to be true, to determine whether this deterioration could be identified by changes in T/QRS height or ST waveform shape. Chronically instrumented near-term sheep fetuses (124 +/- 1 day) were subjected to 1-minute umbilical cord occlusions every 5 minutes (normoxic group, 8 fetuses; hypoxic group, 10 fetuses) for a total of 4 hours or until mean arterial blood pressure fell below 20 mm Hg for 2 successive occlusions. The spontaneous hypoxic, but not normoxic, fetuses had progressive compromise during repeated umbilical cord occlusions, with severe, progressive metabolic acidosis (pH, 7.07 +/- 0.14; base deficit,13 +/- 1.5 mmol/L vs 7.34 +/- 0.07 mmol/L; base deficit after the final occlusion, 1.1 +/- 1.4 mmol/L; P < .001), and hypotension (24 +/- 2 mm Hg vs 45.5 +/- 3 mm Hg; P < .0001); 4 hypoxic fetuses were unable to complete the 4-hour series of occlusions. The hypoxic group showed a much greater increase in T/QRS ratio during (P < .001) and between occlusions. Biphasic ST segment waveforms were not seen in either group either during or between occlusions. Exaggerated elevation of the T/QRS ratio during decelerations in early labor may be a useful marker of greater myocardial anaerobic stress (eg, because of pre-existing spontaneous hypoxia), but not of the development of fetal acidemia or hypotension.

Cardiac Disease in Pregnancy

After completing this article, readers should be able to: 1. Describe how the cardiovascular changes of pregnancy can affect the woman who has cardiac disease. 2. Review the importance of preconception counseling. 3. Discuss the purpose of a multidisciplinary team approach to the management of the woman who has cardiac disease during pregnancy. 4. Review delivery management of women who have cardiac disease. Pregnancy causes considerable physiologic change in women, particularly in their cardiovascular systems. Circulating blood volume increases dramatically, and cardiac output increases up to 50% by the end of pregnancy. Pregnant women who have cardiac disease must be able to accommodate these normal changes to have a successful pregnancy. Inability to do so can result in increased morbidity and mortality. Cardiac disease is an important cause of nonobstetric mortality during pregnancy and can result in significant morbidity. (1)(2) Approximately 10% of all maternal deaths in the United States can be attributed to cardiac disease, a number that has remained consistent for the last half century. (1) In one study of 1,000 pregnant women who had various types of cardiac disease and were followed by the same health-care team over a 10-year period, more than 75% of the women had no complications during pregnancy. (2) Among the remaining 25%, the following complications were seen most often: The overall maternal mortality rate in this group was 2.7%, and the stillbirth and spontaneous abortion rate was 7.7%. Cardiac disease covers a wide range of conditions, including congenital heart disease, acquired disease such as rheumatic valvular disease, and coronary disease. It is estimated that 1% to 3% of women either have cardiac disease entering pregnancy or are diagnosed with cardiac disease while they are pregnant. …

WS12‐07Fetal venous and arterial circulation in hypoxic IUGR. From adaptation to decompensation

ObjectiveTo evaluate the changes in flow velocity waveforms in the mid‐cerebral artery and in the transverse cerebral sinus in growth restricted fetuses and to correlate these changes between them and with (1) flow velocity waveforms in the ductus venosus and (2) changes in computerized analysis of fetal cardiotocogram.DesignFetuses between 22 and 37 weeks' gestation with an estimated fetal weight below the 5th centile were included in this prospective longitudinal study. Doppler measurements in the umbilical artery, descending aorta, middle cerebral artery, transverse cerebral sinus and ductus venosus were recorded. Fetal heart rate was analyzed by a computer system according to the Dawes‐Redman criteria.ResultsBlood flow within the midcerebral artery and that in the cerebral transverse sinus follow a mirror image distribution. Arterial redistribution is already present when alteration in the venous cerebral circulation develops.We measured a significant correlation between pulsatility index in the transverse cerebral sinus and in the ductus venosus over the study period and at delivery. There was a negative correlation between these indices and short and long‐term variability of the fetal heart rate. There was a parallel increase in pulsatility in the ductus venosus and the transverse cerebral sinus. These changes were inversely correlated with fetal heart rate variability and preceded fetal distress.ConclusionCerebral venous blood flow in IUGR fetuses may be a useful additional investigation to (1) understand better the mechanism of cerebral redistribution in hypoxemic IUGR and (2) to discriminate between fetal adaptation and fetal decompensation in chronic hypoxemia.

WS12‐04Fetal hemodynamics and growth restriction

Intrauterine growth restriction (IUGR) is a common symptom of many possible maternal‐fetal pathologies and/or the expression of a genetic alteration; by far, the most common etiology is related to chronic fetal hypoxemia. Fetal hypoxemia may be the result of different feto‐maternal pathophysiological processes which can produce completely different fetal hemodynamic modifications, not only in relation to the quality but particularly in relation to the chronology of the hemodynamic events. However, fetal hypoxia is mostly due to placental vascular insufficiency and it is important to point‐out that fetal hypoxemia‐acidemia is part of the terminal pathway starting from placental functional and structural alterations, through fetal IUGR, leading to intrauterine fetal death. Doppler evaluation of fetal arterial districts is important for the diagnosis of the fetal hemodynamic adaptation to the hypoxemia. Our observations suggest that, in the evaluation of fetal hemodynamics, it is important to consider also the intracardiac and the venous hemodynamics, focusing the study on the evaluation of the output tracts, the atrio‐ventricular flow and on vessels like the ductus venosus, inferior vena cava, umbilical vein. Keeping the time of the hemodynamic alterations in these vessels and/or districts, which are characteristic signs of the incipient heart failure, may be one of the key for the solution for one of the main obstetrical problem: the diagnosis of fetal decompensation phase.